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This paper describes a new combined impedance plethysmographic (IPG) and electrical bioimpedance spectroscopic (BIS) instrument and software that allows noninvasive real-time measurement of segmental blood flow and changes in intracellular, interstitial, and intravascular volumes during various fluid management procedures. The impedance device can be operated either as a fixed frequency IPG for the quantification of segmental blood flow and hemodynamics or as a multi-frequency BIS for the recording of intracellular and extracellular resistances at 40 discrete input frequencies. The extracellular volume is then deconvoluted to obtain its intra-vascular and interstitial component volumes as functions of elapsed time. The purpose of this paper is to describe this instrumentation and to demonstrate the information that can be obtained by using it to monitor segmental compartment volumes and circulatory responses of end stage renal disease patients during acute hemodialysis. Such information may prove valuable in the diagnosis and management of rapid changes in the body fluid balance and various clinical treatments.

In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.

Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the mechanisms, diagnosis, clinical consequences, and conditions associated with pseudohyponatremia, and future developments for its elimination. The two methods involved assess the serum sodium concentration ([Na]S) using sodium ion-specific electrodes: (a) a direct ion-specific electrode (ISE), and (b) an indirect ISE. A direct ISE does not require dilution of a sample prior to its measurement, whereas an indirect ISE needs pre-measurement sample dilution. [Na]S measurements using an indirect ISE are influenced by abnormal concentrations of serum proteins or lipids. Pseudohyponatremia occurs when the [Na]S is measured with an indirect ISE and the serum solid content concentrations are elevated, resulting in reciprocal depressions in serum water and [Na]S values. Pseudonormonatremia or pseudohypernatremia are encountered in hypoproteinemic patients who have a decreased plasma solids content. Three mechanisms are responsible for pseudohyponatremia: (a) a reduction in the [Na]S due to lower serum water and sodium concentrations, the electrolyte exclusion effect; (b) an increase in the measured sample's water concentration post-dilution to a greater extent when compared to normal serum, lowering the [Na] in this sample; (c) when serum hyperviscosity reduces serum delivery to the device that apportions serum and diluent. Patients with pseudohyponatremia and a normal [Na]S do not develop water movement across cell membranes and clinical manifestations of hypotonic hyponatremia. Pseudohyponatremia does not require treatment to address the [Na]S, making any inadvertent correction treatment potentially detrimental.

The relationship between sodium, blood pressure and extracellular volume could not be more pronounced or complex than in a dialysis patient. We review the patients' sources of sodium exposure in the form of dietary salt intake, medication administration, and the dialysis treatment itself. In addition, the roles dialysis modalities, hemodialysis types, and dialysis fluid sodium concentration have on blood pressure, intradialytic symptoms, and interdialytic weight gain affect patient outcomes are discussed. We review whether sodium restriction (reduced salt intake), alteration in dialysis fluid sodium concentration and the different dialysis types have any impact on blood pressure, intradialytic symptoms, and interdialytic weight gain.

Herbal medicine, a form of complementary and alternative medicine (CAM), is used throughout the world, in both developing and developed countries. The ingredients in herbal medicines are not standardized by any regulatory agency. Variability exists in the ingredients as well as in their concentrations. Plant products may become contaminated with bacteria and fungi during storage. Therefore, harm can occur to the kidney, liver, and blood components after ingestion. We encourage scientific studies to identify the active ingredients in herbs and to standardize their concentrations in all herbal preparations. Rigorous studies need to be performed in order to understand the effect of herbal ingredients on different organ systems as well as these substances' interaction with other medications.

The key message from the 1958 Edelman study states that combinations of external gains or losses of sodium, potassium and water leading to an increase of the fraction (total body sodium plus total body potassium) over total body water will raise the serum sodium concentration ([Na]S), while external gains or losses leading to a decrease in this fraction will lower [Na]S. A variety of studies have supported this concept and current quantitative methods for correcting dysnatremias, including formulas calculating the volume of saline needed for a change in [Na]S are based on it. Not accounting for external losses of sodium, potassium and water during treatment and faulty values for body water inserted in the formulas predicting the change in [Na]S affect the accuracy of these formulas. Newly described factors potentially affecting the change in [Na]S during treatment of dysnatremias include the following: (a) exchanges during development or correction of dysnatremias between osmotically inactive sodium stored in tissues and osmotically active sodium in solution in body fluids; (b) chemical binding of part of body water to macromolecules which would decrease the amount of body water available for osmotic exchanges; and (c) genetic influences on the determination of sodium concentration in body fluids. The effects of these newer developments on the methods of treatment of dysnatremias are not well-established and will need extensive studying. Currently, monitoring of serum sodium concentration remains a critical step during treatment of dysnatremias.

BackgroundHemodialysis corrects metabolic acidosis by transferring bicarbonate or bicarbonate equivalents across the dialysis membrane from the dialysis fluid to the plasma. With the conventional three-stream bicarbonate-based dialysis fluid delivery system, a change in the bicarbonate concentration results in changes in the other electrolytes. In practice, the dialysis machine draws either a little less or more from the bicarbonate concentrate and a little more or less from the acid concentrate, respectively in a three-stream delivery system. The result not only changes the bicarbonate concentration of the final dialysis fluid but also causes a minor change in the other ingredients.MethodsWe propose a four-stream bicarbonate-based dialysis fluid delivery system consisting of an acid concentrate, a base concentrate, a product water, and a new sodium chloride concentrate.ResultsBy adjusting the flow rate ratio between the sodium chloride and sodium bicarbonate concentrates, one can achieve the desired bicarbonate concentration in the dialysis fluid without changing the concentration of sodium or ingredients in the acid concentrate. The chloride concentration mirrors the change in bicarbonate but in the opposite direction.ConclusionA four-stream, bicarbonate-based dialysis fluid delivery system allows the bicarbonate concentration to be changed without changing the other constituents of the final dialysis fluid.

Initial imaging evaluation of hydronephrosis of unknown etiology is a complex subject and is dependent on clinical context. In asymptomatic patients, it is often best conducted via CT urography (CTU) without and with contrast, MR urography (MRU) without and with contrast, or scintigraphic evaluation with mercaptoacetyltriglycine (MAG3) imaging. For symptomatic patients, CTU without and with contrast, MRU without and with contrast, MAG3 scintigraphy, or ultrasound of the kidneys and bladder with Doppler imaging are all viable initial imaging studies. In asymptomatic pregnant patients, nonionizing imaging with US of the kidneys and bladder with Doppler imaging is preferred. Similarly, in symptomatic pregnant patients, US of the kidneys and bladder with Doppler imaging or MRU without contrast is the imaging study of choice, as both ionizing radiation and gadolinium contrast are avoided in pregnancy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Implementing eHealth requires technological advancement, universal broadband and internet access, and devices to conduct telemedicine and remote patient monitoring in end-stage kidney disease patients receiving home dialysis. Although eHealth was beginning to make inroads in this patient population, the COVID-19 pandemic spurred telemedicine usage when many regulations were waived during the Public Health Emergency to limit the spread of infection by endorsing social distancing. At the same time, two-way communication automatic peritoneal dialysis cyclers were introduced to advance remote patient monitoring. Despite the numerous advantages and potential benefits afforded by both procedures, challenges and untapped resources remain to be addressed. Continuing research to assess the use of eHealth and technological innovation can make eHealth a powerful tool in home dialysis. We review the past, present and future of eHealth and remote patient monitoring in supporting home dialysis. [ABSTRACT FROM AUTHOR]

Using a Likert scale ranging from 1 to 10 (10 = extremely satisfied), patients reported an average telehealth satisfaction score of 8.0, with 42% of patients indicating the highest satisfaction rating and 74% indicating a score of 7 or higher (Figure 1). Although patients previously reported positive experiences with telemonitoring in the home dialysis setting,[2] various aspects of telehealth that are unique to the hemodialysis unit may have contributed to patient satisfaction in our study. Centers for Medicare and Medicaid Services (CMS) issued a series of telehealth waivers in 2020 that lifted geographic restrictions and expanded originating sites to include the home and dialysis units.[1] For the first time, all nephrology practitioners in the United States could conduct in-center hemodialysis patient visits through telehealth. [Extracted from the article]

Introduction: Telehealth is a potential solution to persistent disparities in health and health care access by eliminating structural barriers to care. However, its adoption in urban underserved settings has been limited and remains poorly characterized. Methods: This is a prospective cohort study of patients receiving telemedicine (TM) consultation for specialty care of diabetes, hypertension, and/or kidney disease with a Federally Qualified Health Center (FQHC) as the originating site and an academic medical center (AMC) multispecialty group practice as the distant site in an urban setting. Primary data were collected onsite at a local FQHC and an urban AMC between March 2017 and March 2020, before the COVID-19 pandemic. Clinical outcomes of study participants were compared with matched controls (CON) from a sister FQHC site who were referred for traditional in-person specialty visits at the AMC. No-show rates for study participants were calculated and compared to their no-show rates for standard (STD) in-person specialty visits at the AMC during the study period. A patient satisfaction questionnaire was administered at the end of each TM visit. Results: Visit attendance data were analyzed for 104 patients (834 visits). The no-show rate was 15%. The adjusted odds ratio for no-show for TM versus STD visits was 1.03 [0.66–1.63], p = 0.87. There were no significant differences between TM and CON groups in the change from pre- to intervention periods for mean arterial pressure (p = 0.26), serum creatinine (p = 0.90), or estimated glomerular filtration rate (p = 0.56). The reduction in hemoglobin A1c was significant at a trend level (p = 0.053). Patients indicated high overall satisfaction with TM. Discussion: The study demonstrated improved glycemic control and equivalent outcomes in TM management of hypertension and kidney disease with excellent patient satisfaction. This supports ongoing efforts to increase the availability of TM to improve access to care for urban underserved populations. [ABSTRACT FROM AUTHOR]

We propose a new 45X, four‐stream, triple‐concentrate, bicarbonate‐based dialysis fluid delivery system, allowing a wide range of dialysis fluid sodium concentrations\\ (DFNa) without affecting the concentrations of other crucial solutes. The four streams consist of product water (W), and concentrates with sodium chloride (S), acid (A), and sodium bicarbonate (B). An adjustment in the DFNa in this new system requires changes only in the W and S concentrate streams. The ingredients in A and B concentrates do not change. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic poses significant challenges to patients with end-stage kidney disease who receive treatment in outpatient dialysis centers. These patients represent a fragile population that is at higher risk for both infection and transmission. At the start of the pandemic, many suspected COVID-19 dialysis patients were diverted to the emergency department (ED) for testing/treatment, placing a tremendous burden on the ED and inpatient dialysis units. Several recommendations and guidelines have been established to optimize patient care while also decreasing the burden on the ED and inpatient dialysis units and maximizing the ability to perform outpatient hemodialysis. As the pandemic continues, dialysis facilities will have an increasing burden to provide safe and accessible dialysis, while also being able to direct patients to the ED for either emergent dialysis or COVID-19 treatment/testing. We reviewed opinions, recommendations and guidelines developed by professional organizations and dialysis facilities for the management of "patients under investigation" (PUIs) and COVID-19 positive patients that depend on whether the suspicion occurs while the patient is at home vs. at the dialysis center. [ABSTRACT FROM AUTHOR]

Peritoneal dialysis catheter complications that require nonsurgical or noninvasive correction by peritoneal dialysis (PD) nurses or practitioner are reviewed. Topics reviewed include compromised PD fluid flow, pericatheter fluid leakage, mechanical integrity disruption, catheter extrusion, and exit site/tunnel complications. [ABSTRACT FROM AUTHOR]

Haemoperitoneum was observed in a peritoneal dialysis (PD) patient after undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA was performed to evaluate a pancreatic cyst seen on a prekidney transplant evaluation abdominal CT scan. Haemoperitoneum cleared with a PD exchange. In this case report, we discuss aetiologies for bleeding risks in patients with chronic kidney disease and focus on haemoperitoneum in patients receiving PD. We will also explore treatment options to minimise bleeding associated with an abdominal procedure such as EUSFNA. [ABSTRACT FROM AUTHOR]

Patients receiving peritoneal dialysis (PD) encounter an increased risk for infection, bleeding, and PD fluid leakage after abdominal surgery. These complications may affect the future use of PD. Appropriate patient preparation may mitigate complications. Certain complications or procedures allow patients to remain on PD while others require transition to hemodialysis. We review the etiology and management of infection, bleeding, and PD fluid leakage associated with abdominal surgery as well as the relationship of specific abdominal procedures to continuing PD. [ABSTRACT FROM AUTHOR]

Hypercalcaemia is a common diagnosis with the majority of cases resulting from hyperparathyroidism or malignancy. We report a rare case of persistent symptomatic hypervitaminosis D-induced hypercalcaemia in an individual taking 50 000 IU of vitamin D supplement daily for several months following a diagnosis of vitamin D deficiency. His hypercalcaemia was initially treated with calcitonin and intravenous fluids, but due to recurrent symptomatic hypercalcaemia after discharge, additional treatment with glucocorticoids and bisphosphonates was warranted during his second admission. The pathophysiology of hypercalcaemia from vitamin D intoxication results from the long-term effects of vitamin D storage in adipose tissue. In the present case, we discuss this pathophysiology and treatment approaches in the context of increasing awareness of and testing for vitamin D deficiency, and growing access to over-the- counter supplements. [ABSTRACT FROM AUTHOR]

US Medicare beneficiaries receiving home dialysis will have the opportunity to engage in telehealth beginning in 2019. This new paradigm, if successful, will be instituted internationally. Any changes in healthcare delivery, such as using telehealth, will affect the process and quality. Quality of care metrics is discussed, and they can be used to evaluate the three domains of structure, process, and outcome when applied to assess telehealth's impact and quality on the dialysis population. [ABSTRACT FROM AUTHOR]

Introduction: Peritoneal dialysis is a home-based therapy for individuals with end-stage renal disease. Telehealth, and in particular - remote monitoring, is making inroads in managing this cohort.Methods: We examined whether daily remote biometric monitoring (RBM) of blood pressure and weight among peritoneal dialysis patients was associated with changes in hospitalization rate and hospital length of stay, as well as outpatient, inpatient and overall cost of care.Results: Outpatient visit claim payment amounts (in US dollars derived from CMS data) decreased post-intervention relative to pre-intervention for those at age 18-54 years. For certain subgroups, non- or nearly-significant changes were found among female and Black participants. There was no change in inpatient costs post-intervention relative to pre-intervention for females and while the overall visit claim payment amounts increased in the outpatient setting slightly (US$511.41 (1990.30) vs. US$652.61 (2319.02), p = 0.0783) and decreased in the inpatient setting (US$10,835.30 (6488.66) vs. US$10,678.88 (15,308.17), p = 0.4588), these differences were not statistically significant. Overall cost was lower if RBM was used for assessment of blood pressure and/or weight (US$-734.51, p < 0.05). Use of RBM collected weight was associated with fewer hospitalizations (adjusted odds ratio 0.54, 95% confidence interval 0.33-0.89) and fewer days hospitalized (adjusted odds ratio 0.46, 95% confidence interval 0.26-0.81). Use of RBM collected blood pressure was associated with increased days of hospitalization and increased odds of hospitalization.Conclusions: RBM offers a powerful opportunity to provide care to those receiving home therapies such as peritoneal dialysis. RBM may be associated with reduction in both inpatient and outpatient costs for specific sub-groups receiving peritoneal dialysis. [ABSTRACT FROM AUTHOR]

Kidney transplantation is an excellent treatment option for many patients, providing a quality of life that is superior to that experienced by patients on dialysis. Despite its advantages, there are certain health implications that transplant recipients must face. In this article, Susie Lew et al review the nutritional factors that need to be considered to prevent health issues after kidney transplant [ABSTRACT FROM AUTHOR]